Despite important advances in medical treatment, cancer remains the second leading cause of death in the USA with one in two cancer patients dying of his/her disease. Often seriously ill and dying cancer patients are caught within the revolving door of the acute care hospital and the nursing home (NH). Our preliminary work found that nearly one in three Medicare beneficiary decedents with a diagnosis of cancer are in a NH in the last 90 days of life, with many transitions in the last 3 days of life. In this application, we propose to examine the quality of cancer care based on merged Minimum Data Set and Medicare Claims files by creating both prospective and retrospective cohorts of cancer patients to quantify health care transitions and to-be- developed measures of potentially burdensome transitions. Current measures of health care transitions focus on the discharge from the hospital when an important concern is whether that hospitalization (i.e. transition) was appropriate in the first place. Using a modified Delphi technique with focus groups and expert advisory panel, we propose to develop measures of potentially burdensome transitions (Specific Aim I), document their variation, and examine the individual, organizational characteristics, and health market association of these proposed prospective and retrospective measures (Specific Aim II). While quality indicators based on Medicare claims are relatively inexpensive to implement, an important catch is not knowing whether the observed variation in each of the proposed measures reflects informed patient preferences. Thus, as part of this application, we will undertake a preliminary work to develop a survey sampling strategy for an R01 grant application that will validate these claims based measures with surveys of bereaved family members using existing, validated survey measures that examine care coordination and whether cancer care is patient- and family-centered (Specific Aims III). The Institute of Medicine, pay for performance (P4P), and the development of accountable care organizations call for development of measures that examine the longitudinal experience of Medicare beneficiaries. The results of this project will provide claims-based measures that could be used to evaluate Patient Protection and Affordable Care Act of 2010 efforts to create accountable care organizations, which aim to foster integration and coordination of care. Such measures potentially could help inform how best to structure health care for persons with advanced cancer.